WEAPON & WOUND Dr.AbdulWAHID M Salih Ph.D. Surgery
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WEAPONS Some wound characteristics of different weapons The
power of a missile depends on how much kinetic energy is given up
when it strikes tissue. The energy : formula E = mv2 m= mass and v=
velocity.
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Bullets Small entrance wound and a large exit wound.
Fragmentation of the bullet will cause severe wounds
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Fragments Caused by explosive devices, such as; Bombs, mortars,
shells, rockets and grenades. The distance between the wounded
person and the explosion determines the outcome. The blast wave
from an explosion might cause rupture of the ear drums and of
gas-containing viscera, such as the stomach or bowels hemorrhage in
the lungs, without any penetrating wound.
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Mines Exploding devices Traumatic amputation of foot or leg,
Combined with multiple severe wounds. The wounds are all severely
contaminated by mud, grass, pieces of shoes and clothes
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Mines Draw Heavily On Resources : need a long operation time
many operations blood transfusions dressing material a long
hospital stay and a difficult period of rehabilitation, includes
the fitting of an artificial limb
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principles of management of war wounds: Complete wound excision
; Delayed primary closure ; No internal bone fixation Antibiotics ;
Antitetanus
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Record Aspects of the wounds The treatment Patients triage
category. Whole body, including the back, must be examined.
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clinical examination All clothing should be removed in so far
as possible, bearing in mind local religious and cultural factors.
Careful clinical examination vascular supply to a limb any nerve
lesion.
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multiple wounds those on the posterior aspect of the body and
limbs should be dealt with before those on the anterior
aspect.
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INFECTION IN WAR WOUNDS War wounds are grossly contaminated
with bact Inevitably become infected unless treated quickly and
correctly. Should be treated by excision of the wound within six
hours.
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Early and thorough wound excision: Reduces chances of death
from gas gangrene or generalized infection ; Reduces the number of
operations Allows delayed primary closure to be successful.
Shortens the stay in hospital.
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War wounds are often multiple Usually no more than 1 mm of the
skin edge need be removed.
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DRESSINGS Wounds should be covered by clean dressings to avoid
further soiling.
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Dressings change Wounds should not have dressings changed until
delayed primary closure (DPC) The exception to this will be when ;
1.persisting contamination 2.infection develop
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Treatment of a soft tissue wound 1.Excision of the wound;
2.Delayed primary closure. Wounds should be left wide open, without
any suture of skin or deep structures.
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Excise Dead muscle All dead muscle must be excised. Dead muscle
is the ideal medium for clostridial infection leading to gas
gangrene. The track of the missile may be surrounded by dead
muscle.
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Dead muscle not healthy not contract Not bleed when cut must be
excised until : healthy, contractile, bleeding muscle is
found.
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Foreign bodies Remove ; Blood clot Dirt Debris Missile
fragments Clothing Vegetation Gentle and copious irrigation with
saline to wash out the residual debris and blood clot.
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Fascial compartments Muscle Ischaemia. Interference With The
Blood Supply Need Decompression By Fasciotomy
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DO NOT Open fresh planes in healthy tissue. Explore
unnecessarily for metallic fragments ; left in situ.
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Closed primarily Face, neck, scalp and genitals. Soft tissues
of the chest wall to make an airtight closure Head. The dura can
rarely be closed directly -- Joints. Synovial membranes should be
closed Hand ; Tendons and nerves must be covered by healthy tissue.
Blood vessels. Those blood vessels that have been repaired should,
if possible, be covered by viable muscle.
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ANTIBIOTICS Penicillin, 5 mega-units 6-hourly intravenously,
substituted by oral penicillin, 500 mg 6-hourly 5 days
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TETANUS Clostridium tetani is the causative organism produces
an extremely potent toxin ; tetanospasmin which spreads by
intra-axonal routes, or by bloodborne invasion. The toxin affects
the nervous system at the motor end-plate by inhibiting the release
of acetylcholine. typical spastic phenomena
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All patients whatever their immunization Benzylpenicillin 5
million units i.V. 6-hourly; Thorough excision of the wound.
Vaccines are toxoids; they prevent disease. Anti-toxins are used
when a problem already exists
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Immunized patients Booster Dose of tetanus toxoid 0.5 ml
i.m.
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Non-immunized patients Anti-tetanus human immunoglobulin Ig 500
i.U. I.M. (Adults) If more than 24 hours since injury; Tetanus
toxoid 0.5 ml i.M. Tetanus toxoid 0.5 ml to be repeated at four
weeks and again six months later.
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Treatment of established tetanus After the wound has been
excised penicillin given nursed in an environment devoid of
stimulation. anti-tetanus human immunoglobulin (3000 6000 I.U.i.m.)
Spasms; intermittent doses of diazepam (2-20 mg i.v. hourly).
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DELAYED PRIMARY CLOSURE Within seven days of injury. By simple
approximation of the deep structures and skin, without
tension.
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The aim of DPC Is to close the wound during the fibroblastic
phase of wound healing (3rd and 6th days) Some wounds can be closed
with safety earlier: Wounds of the face, neck and scrotum (3rd day)
Upper extremity (4-5th day) Lower extremities (5-7th day).
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Tissue loss If there has been significant tissue loss ; Skin
grafts, Or Skin Or Musculocutaneous Flap
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Abdominal wounds All penetrating abdominal wounds Should be
explored : The mortality of a negative laparotomy is low Whereas an
unoperated abdominal wound is often fatal.
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Prognosis of abdominal wounds 1. The type of missile and amount
of energy transferred; 2.The organs hit and their number; 3.The
time since injury.
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??? Example of quotations
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write short notes on; A flail segment compartment syndrome
penetrating chest injuries
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What is; Triage? Fasciotomy ?
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How to manage; Haemorrhage and restore the volume due to bullet
injury to abdomen? War wounds Tibial copound fracture Pulses
(abscent pulses in the affected limb) Pallor (loss of normal color)
?